Clinical Appeals Nurse (PRN)

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

Responsible for reviewing medical records and preparing clinical appeals in response to medical necessity denials and diagnosis-related groups (DRG) reassignments

Prepare and submit clinical appeals in response to denials from managed care organizations, governmental entities, and Recovery Audit Contractors (RACs) for hospital clients Review medical records and utilize industry guidelines, Medicare policies, and best practice standards to support appeal arguments Participate in Administrative Law Judge (ALJ) Hearings, presenting oral arguments to support the reversal of Medicare denials Analyze denial patterns and contribute insights to help reduce future denials Collaborate with the appeals team and hospital clients to provide updates on appeal statuses and outcomes Maintain current knowledge of healthcare regulations, coding guidelines, and payer policies relevant to the appeals process